Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 152W00000X | Optometrist | IL | |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | IL | |
N | 152WL0500X | Optomitrist - Low Vision Rehabilitation | IL |
NPI | 1346230604 |
---|---|
Provider Name | Dr. Chula Lerdvoratavee |
First Address | Montgomery, IL 60538-1634 |
Second Address | Montgomery, IL 60538-1634 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/10/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U24506 | (02) | IL |